Ergonomic Injury Record Review

To root out ergonomic injuries you must be proactive. The first step is to do a record review and create a “snapshot” of worker injuries, so you can analyze causes and identify trends.

HOW TO USE THIS TOOL

Use and adapt this form to use at your workplace to perform an effective records review or ergonomic injuries.

 

A. REVIEWER IDENTIFICATION

Team Leader: __________________________________________________
Tel. No.: ______________________________________________________
Record Reviewer: _______________________________________________
Tel. No.: ______________________________________________________
Department: ____________________________________________________
Review Date: ___________________________________________________

B. RECORD IDENTIFICATION

Employee Name (or Record ID number if confidential): ______________________
Employee Job Title: ___________________________________________________
Record Reviewed: _____________________________________________________ 

[  ] OSHA or OHS form (specify) ________________________________

[  ] Incident report

[  ] Workers’ comp claim

[  ] Other (specify) ____________________________________

Record Date: _______________________________________________

C. INJURY IDENTIFICATION

Injury Date: _______________________________________________________

Injury Type (specify body part(s) affected): _____________________________

Workplace Location of Injury: ________________________________________

Activity Employee Was Performing When Injured: __________________________

Type of Device, Supply, Equipment or Workstation Involved (include serial number if applicable): ­­­­­­­________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Reviewer’s Signature: _________________

Date: ______________